Bled dry

Most visitors to this blog will probably be aware that for centuries bloodletting played a central role in Western medicine. This is partly the result of the extraordinarily long-lasting influence of the Greek physician Galen, whose humoral theory underpinned medical practice until the Renaissance. Strangely, bleeding remained commonplace until much later, persisting well into the nineteenth century. I recently found a letter in a medical journal of the 1890s, written by a specialist who advised a return to bloodletting as a possible new treatment for aortic aneurysm. By then, his was certainly a lone voice.

One of the most notorious advocates of bloodletting was the American Benjamin Rush, memorably dubbed ‘the remorseless Bleeder’ by his implacable critic William Cobbett. I have previously written about Rush for The Lancet, in an article you’ll find here. During a major epidemic of yellow fever in Philadelphia in 1793, Rush began to treat patients by taking dramatic amounts of blood, encouraging his medical students “to bleed not only by ounces or in basins, but by pounds and by pailfuls”.

Even Rush might have thought twice before administering the treatment in this case from 1827, however. It was reported in The Lancet sixty years later, by a Dr James Martin:

A man who was going home from the town (Maryborough) attacked another (who carried with him a bayonet for his protection) with a loaded whip. The attack was repelled by a thrust of the bayonet, and this thrust floored the man, who fell down and became at once unconscious. He remained in this state during the fifty-three hours he survived, and meanwhile ninety-six ounces of blood were taken from him, at intervals, during this time.

Ninety-six ounces is five pints of blood. The average human body contains eight pints, so he lost most of his circulation at the hands of a medic. As it turns out, the practitioner wasn’t even – strictly speaking – a doctor:

Notwithstanding this deprivation, however, he did not die from loss of blood. On the contrary, the young man – who was just on the point of qualifying – who remained in constant attendance on him, maintained to his dying day that this patient would have lived had the surgeon in charge permitted him – the young attendant – to take more blood from him.

If he had taken much more blood from him, there wouldn’t have been any left. I hope it goes without saying that the treatment adopted was pretty much the worst possible. In cases of stab injury suspected to have lacerated major organs or vessels, blood loss can rapidly cause circulatory shock, a condition in which low flow of blood results in organ failure, inadequate cardiac output and eventually cardiac arrest. Removing more blood just makes this process inevitable, and hastens death.

On examination of the remains there was only one mark of injury on them – viz, a small triangular wound two inches below the edge of the ribs on the left side. The weapon seems to have traversed the stomach and penetrated the diaphragm, the pericardium, and the wall of the left ventricle.

From the sound of it, the injury was almost certain to be fatal whatever happened. The left ventricle – the main pumping chamber of the systemic circulation – operates at high pressure, and even small punctures can rapidly cause catastrophic blood loss. Stitching such a wound was not even attempted until 1895 (with the first success the following year).

It is, in either case, not easy to see how phlebotomy [opening a vein], even usque ad deliquium, could have prolonged this poor fellow’s life.

Yet such was one of his quasi-qualified attendant’s belief; and this belief affords of itself another illustration – were any such wanted – of the fact that nothing takes so much killing as an old superstition.

Quite. In the young medical student’s defence, there was nothing he could have done. But let’s hope that later patients did not suffer too much from his enthusiasm for the lancet and the bleeding bowl.